A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Expresses that they cannot get enough air to breathe.

Respiratory rate of 7 breaths/minute.

Bilateral wheezing on auscultation.

Pulse oximeter reading of 89% on room air.

Answer and Explanation

The Correct Answer is B

A) Expresses that they cannot get enough air to breathe: While this statement suggests respiratory distress, it is not as objective an assessment finding as a respiratory rate of 7 breaths/minute. Objective measurements are typically more reliable indicators for initiating interventions.
B) Respiratory rate of 7 breaths/minute: A respiratory rate of 7 breaths/minute is indicative of respiratory depression, which is a potential side effect of opioid analgesics like morphine sulfate. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering a prescribed PRN dose of naloxone is appropriate to counteract the respiratory depression and prevent further complications.
C) Bilateral wheezing on auscultation: Wheezing is more commonly associated with bronchoconstriction or airway obstruction rather than opioid-induced respiratory depression. Naloxone is not indicated for wheezing unless there is concurrent opioid-induced respiratory depression.
D) Pulse oximeter reading of 89% on room air: While a pulse oximeter reading of 89% indicates hypoxemia, it may not be solely due to opioid-induced respiratory depression. Other factors, such as hypoventilation, ventilation-perfusion (V/Q) mismatch, or lung disease, could contribute to decreased oxygen saturation. Administering naloxone solely based on pulse oximetry readings may not address the underlying cause adequately. It is essential to assess the client comprehensively, considering clinical signs and symptoms along with objective data.

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Correct Answer is B

Explanation

A) Diminished renal output:
Diminished renal output could be a potential concern with cefoxitin administration, as it is primarily excreted by the kidneys. However, it is not specifically related to the client’s allergy to penicillin. While it warrants monitoring, it is not the most critical finding to report in this context.

B) Pruritis and macular rash:
The development of pruritis (itchiness) and a macular rash (flat, discolored skin lesions) following the administration of cefoxitin in a client with a documented allergy to penicillin is a significant finding. It suggests a possible allergic reaction to cefoxitin, which belongs to the cephalosporin class of antibiotics. Cross-reactivity between penicillin and cephalosporins is well-documented, with some cephalosporins having a higher risk of allergic reactions in individuals with penicillin allergy. Therefore, pruritis and rash in this context may indicate an allergic response, and it is crucial to report this finding promptly to the healthcare provider for further evaluation and management.

C) Vomiting and diarrhea:
While gastrointestinal symptoms such as vomiting and diarrhea can occur as adverse effects of cefoxitin, they are not specific to an allergic reaction and may occur with various medications. While it is essential to monitor for these symptoms, they are not the most important findings to report in the context of a known penicillin allergy.

D) Vaginal discharge:
Vaginal discharge is not typically associated with an allergic reaction to cefoxitin. While changes in vaginal discharge may be clinically relevant in certain contexts, such as indicating a possible yeast infection or bacterial vaginosis, it is not directly related to the client’s allergy to penicillin or the administration of cefoxitin.

Correct Answer is ["1.7"]

Explanation

To find out how many mL the nurse should administer:

We can set up a proportion to solve for the unknown.

Given:

The prescription is for 1,000,000 units of penicillin G.

The available medication is 1,200,000 units/2 mL.

We can set up the proportion as follows:

1,000,000units/ xmL = 1,200,000units/2mL

Solving for x gives us the volume in mL that the nurse should administer.

Cross-multiplying and solving for x:

X = 1,000,000units×2mL/1,200,000units

After performing the calculation, we find that x equals 1.67 mL.

So, the nurse should administer 1.7 mL (rounded to the nearest tenth) of the medication.

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A client is receiving morphine sulfate via a patient controlled analgesic (PCA) pump postoperatively. Which assessment finding should prompt the nurse to administer a prescribed PRN dose of naloxone?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers the initial dose of cefoxitin to a client whose medical record indicates an allergy to penicillin. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

A client receives a prescription for penicillin G 1,000,000 units intramuscular (IM) daily. The medication is available in 1,200,000 units/2 mL syringe. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["1.7"]

Explanation

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